Influence of patient sex on clinical decision-making in acute heart failure: A risk-adjusted analysis using the MEESSI-AHF score

Background: Risk scores for acute heart failure (AHF) are typically developed without sex-specific models. The MEESSI-AHF score estimates 30-day mortality in patients presenting with AHF to the emergency department (ED). Whether its prognostic accuracy and its influence on clinical decisions are comparable between men and women remains unknown. Methods: We analyzed patients from the EAHFE registry with known sex and complete data to calculate the MEESSI-AHF score. Patients were classified into four risk groups (low, intermediate, high, very high). Sex-based differences were evaluated for 30-day mortality and for ED physicians’ decisions regarding hospitalization and extended (>24 h) ED observation, as well as for hospital physicians’ decisions regarding prolonged hospitalization (>7 days). Logistic regression interaction analyses were performed using both categorical and continuous models (restricted cubic splines). Results: We included 13,042 patients (median age 83 years; 56% women). MEESSI-AHF accurately stratified 30-day mortality overall (2.9%, 9.6%, 18.2%, and 39.7% across risk groups; with a c-statistic of 0.78; p<0.001) and by sex (c-statistics of 0.77 for men and 0.78 for women, p>0.05), with no significant sex interactions in categorical or continuous analyses (all p>0.05). Hospitalization (76%), extended observation in the ED in discharged patients (9%) and prolonged hospitalization (47%) also increased with higher MEESSI-AHF risk, with no evidence of sex interaction in categorical or continuous analyses (all p>0.05). Conclusions: The MEESSI-AHF score estimates risk with similar accuracy in men and women. Clinical decisions regarding hospitalization and discharge (from ED and after hospitalization) appear to be made equally in patients of both sexes with comparable MEESSI-AHF-estimated risk.